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TABLE OF CONTENTS:
FOREWORD BY THE DIRECTOR GENERAL OF THE HEALTH SERVICE, MR TONY O’BRIEN 3
FOREWORD BY THE CHAIR OF THE EXPERT PANEL, PROFESSOR FRANK KEANE 4
EXECUTIVE SUMMARY 5
1. INTRODUCTION 11
2. ETHICAL PERSPECTIVE 18
3. THE CURRENT MEDICAL CARD SYSTEM IN IRELAND 26
4. THE VOICE OF THE PUBLIC, THE PATIENT AND REPRESENTATIVE PANELS 42
5. EXPERT PANEL – APPROACH AND METHODOLOGY 57
6. EXPERT PANEL – CONCLUSIONS 67
7. EXPERT PANEL – RECOMMENDATIONS 70
APPENDIX 1: EXPERT PANEL EXERCISE 73
APPENDIX 2: EXPERT PANEL MEMBERSHIP 79
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FOREWORD BY THE DIRECTOR GENERAL OF THE HEALTH SERVICE, MR TONY
O’BRIEN
Under the Health Act 1970 (as amended), eligibility for health services in Ireland is based primarily
on residency and means. In June 2014, the Government decided to examine options to develop a
policy framework to govern eligibility for health services. The HSE was requested to establish an
expert panel to examine the range of conditions that should be considered as a basis for eligibility of
a range of health services and seek to prioritise such conditions. This report represents the
culmination of the panel’s deliberations, informed by national and international evidence, expert
opinion and a public consultation process where the views of patients, patient representative groups
and professional bodies were sought.
I wish to thank Professor Frank Keane, Chair and Dr Alan Smith, Vice-Chair of the multidisciplinary
expert panel for producing this Report of the Expert Panel on Medical Need for Medical Card
Eligibility in a very short period of time. I would like to join with the Chair and Vice-Chair to add my
gratitude to all the stakeholders involved. I would especially like to thank the members of the public,
patient representative groups and patient advocacy groups for giving up their time and providing the
information needed to ensure that a comprehensive picture of Medical Card eligibility in Ireland was
captured.
The report makes a substantial contribution. It proposes improvements to the current system, calls
on us to strengthen the assessment and measurement of the burden of disease, and to develop our
governance structures by establishing a Strategic Clinical Advisory Group. Implementation of the
recommendations will increase confidence that we are optimising the use of resources in a fair and
equitable manner.
MR TONY O’BRIEN
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FOREWORD BY THE CHAIR OF THE EXPERT PANEL, PROFESSOR FRANK KEANE
The Expert Panel was appointed by the Director General of the Health Service Executive, and it was
with some foreboding that I agreed to chair this eclectic but distinguished group (see Appendix 2).
Over the course of the summer months we had four fairly demanding meetings, interspersed with
substantial reading and study material. Despite the intervening holiday period, we believe we have
managed as a group to bring together and agree a document which sets out to address some of the
difficult and challenging issues around primary healthcare reimbursement and support in Ireland.
I am enormously grateful to all the members of the panel for their always helpful and constructive
inputs, their patience and their steadfast endeavour in seeing the job through. I am particularly
grateful to Dr Alan Smith, Vice-Chair, for the huge contribution he has made, not only to the
choreography of the meetings, but also the great time and commitment he has given to the
preparation of the document. He has been a pleasure to work with.
The second chapter written by Dr Deirdre Madden, Faculty of Law, University College Cork, ‘Ethical
Perspective’, deserves all our thanks for this contribution, which from the start moderated our
thought and judgement processes in a timely and reflective manner.
Our thanks also to Professor Anne Hickey and Mary-Ann O’Donovan and their team in the Division of
Population Health Sciences, Royal College of Surgeons in Ireland for the summary that they provided
from their analysis of the online submissions to the public consultation process. Thanks also to Dr
Marie Eagleton for her summary of the written submissions from patient representative groups.
Both of these are contained in Chapter 4, while the full documents will be published on the HSE
website. The Health Service Executive National Patient Advocacy Unit provided a summary of the
Patient Representative Forum held in Dublin in August, which is also contained in Chapter 4. We are
grateful for this. On behalf of the Expert Panel, I would like to thank the public and patient
representative groups alike for their very significant, caring and thoughtful inputs.
Finally, a document such as this could not have been compiled without the substantial support that
we have received from the Director General himself and from his office, particularly from Joan
Gallagher and Jim O’Sullivan. We were also greatly helped by John Hennessy, National Director of
Primary Care, and his team, including members of the Primary Care Reimbursement Service (PCRS),
Ivan McConkey and others. Last, but by no means least, I would like to acknowledge Helen Kelly not
only for her general helpfulness and valued opinions but also for her fastidious record and minute
keeping.
PROFESSOR FRANK KEANE
5
EXECUTIVE SUMMARY
The General Medical Service (GMS) scheme governs access to Medical Cards in Ireland. The
legislative basis for entitlement to Medical Cards is Section 45 of the Health Act 1970. Legislation
governing the award of Medical Cards does not mention the terms Medical Card or discretionary
Medical Card, but describes people who have full eligibility for health services. Current legislation
requires that an individual’s income and expenditure (i.e. their overall financial situation) must be
taken into account during the assessment process.
Controversy arose over the withdrawal and subsequent re-instatement of a number of ‘discretionary
Medical Cards’ during the course of 2012-14. Contributory factors included a long-established
political and public level of dissatisfaction with the Medical Card system, its perceived complexity
and operational inefficiencies; a general lack of understanding of the term ‘discretionary’ in the
context of Medical Cards; inconsistency in the assessment for Medical Card eligibility; the evolution
over the last 30-40 years of the Medical Card as a valuable asset to obtain and then retain; the
inflated value of the Medical Card arising from the automatic entitlements to a range of non-medical
benefits; and a lack of appreciation of predictable consequences arising from the 2011 centralisation
of the administration of the GMS scheme to the Primary Care Reimbursement Service (PCRS).
In July 2014 the Health Service Executive (HSE) commissioned three projects: (i) An Expert Panel to
firstly address the fundamental question, ‘Can medical conditions be listed in priority order as to
their suitability for Medical Cards?’, and secondly, to provide a contemporaneous overview of the
Medical Card system; (ii) a public and patient group consultation process; and (iii) a review by
Prospectus and Deloitte of the HSE Primary Care Reimbursement Service (PCRS) and its specific role
in the management of the Medical Card system. The outputs of the first two of these projects are
presented in this report prepared by the Expert Panel.
Media analysis of situations reported on during the Medical Card controversy during 2014 clearly
demonstrated a bias towards certain named conditions. Yet, there are many conditions that can be
very disabling and equally deserving – but do not have a ‘voice’ or ‘face’ in the consciousness of
elected representatives, the public or the media – such as very rare diseases, schizophrenia and
other mental health conditions. There are also situations when a patient has a disability or
impairment that does not necessarily have a specific name or diagnosis, such as the frailty associated
with simply growing old.
Many of the respondents to the public and patient consultation process indicated that the current
system for allocation of Medical Cards did not discern the true cost of chronic illness. Many patients
6
with chronic conditions, who do not have Medical Cards, pay up to the maximum for prescription
drugs every month (€144) and visit GPs more frequently than normal, which causes undue financial
hardship. In addition to paying the maximum for prescribed medication, some patients may often
have to pay for other therapies.
There is a desire from the public to see Medical Card eligibility based on the existence of a condition
which gives rise to a specified level of medical need and an assessment of how that condition
impacts their lives, rather than an automatic right to a Medical Card on the basis of having a
particular condition. The public also recognises that having a Medical Card is a gateway to other non-
medical services and that some individuals fear loss of their Medical Card because access to these
other benefits may then be lost. The public have expressed the view that the issuance of Medical
Cards should be for medical benefit and should be decoupled from other non-medical benefits.
There appears to be an inconsistent interpretation and understanding of the requirement to have a
Medical Card to access community primary care services such as physiotherapy, occupational
therapy, speech and language therapy, public health nursing etc. The use of a Medical Card as the
qualifying criterion or allocation mechanism for access to aids and appliances inevitably means that
there is inaccessibility for non-Medical Card holders who have potentially greater clinical need.
The request for and scrutiny of personal financial data can be an upsetting exercise for individuals
being assessed and reviewed for Medical Cards, but it nonetheless remains the only mechanism
available to the health service to fairly and equitably assess undue hardship. Furthermore, a review
of the approach taken in other European countries has confirmed that there is no ideal system for
assessing the medical burden of disease other than by financial means, with variations including the
capping of out-of-pocket expenses, co-payments or some form of universal health coverage.
The advantage of a means test approach is that it is objective and avoids the many difficulties
inherent with the subjectivity of making expert judgements of the impact of a disease on the patient
and their family. The means test approach can also accommodate and respond to the clinical reality
that the severity and impact of a particular condition may change over an unpredictable period of
time.
Although imperfect, the current granting of Medical Cards on a discretionary basis does work to a
certain level, and cards are awarded on this basis whenever it is possible to do so. The Comptroller
and Auditor General’s Report on the accounts of the public services 2012 (published September
2013) reported that in the majority of cases, the cards were awarded on the basis of significant
expenditure in relation to medical costs.
7
The eligibility criteria for a Medical Card, as well as other Primary Care Schemes and their application
processes, have evolved over time in a fragmented manner, and have become complex and poorly
understood by patients, medical staff and administrators alike. It is inevitable that this has
contributed to confusion reflected in the public irritation that has particularly resulted from the 2011
centralisation and standardisation of the PCRS Medical Card renewal, and the current review and
appeals processes. This frustration is further evidenced by the sheer volume of phone calls, enquiries
and Parliamentary Questions received by the PCRS on a daily basis – a workload that diverts scarce
resources away from the processing of Medical Card applications, and which is simply unsustainable
and inefficient.
Centralisation of the Medical Card application process into the PCRS has reduced what was an
unacceptable level of operational variability and will continue to accrue benefits, provided that
satisfactory communication systems are set up with Local Health Offices, GP practices, the public
and elected representatives. The PCRS finds itself in the difficult if not invidious position of
responding to calls for the provision of a more compassionate service while at the same time being
pressed by the Comptroller and Auditor General to incorporate more scrupulous auditing and review
processes on behalf of the taxpayer. A careful balance is required between guarding against
inefficient State spending with the loss of an individual’s rightful entitlement.
There is clearly a societal desire to exercise more compassion and to recognise and support those
coping with specific difficult circumstances arising as a result of financial and/or medical hardship,
which should be accommodated through a more explicit discretionary process.
To address this desire the Expert Panel recommends that:
1. In the absence of international objective and reproducible methods of measuring burden of
disease and illness, it is neither feasible nor desirable to list conditions in priority order for
Medical Card eligibility. A listing approach risks inequity by diagnosis and a further
fragmentation of services.
2. In the context of an ethical approach to the allocation of finite resources, the current system
as it stands is not without its merits for the great majority.
3. The operational deficiencies which currently exist are addressed using an ethical principles
framework approach. There are opportunities for significant improvements in the current
system using this approach to (a) ensure that any priority setting process is more transparent;
(b) involves all stakeholders; (c) delivers similar outcomes for those in broadly similar
circumstances; (d) takes account of health outcomes in the context of a finite health budget,
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and (e) is sufficiently flexible and attentive to the most vulnerable individuals and those with
critical needs.
4. The calculation of financial hardship or means testing should be the primary responsibility of a
Government Department or body other than the health service.
5. The role of the health service would appear to be more appropriately qualified to use third-
party provided means-tested information, and to define and then identify ‘medical hardship’
or ‘burden of disease’.
6. The governance structure of the PCRS should be published. It should detail responsibility and
accountability structures for the administration of the Medical Card Scheme.
7. The separation of the PCRS Medical Card Scheme from the PCRS re-imbursement [of Primary
Care Contractors] function should be considered.
8. Financial hardship or means testing should remain the main discriminator for selecting the
large majority of those eligible for a Medical Card, which is consistent with other health
systems in the European Union.
9. Where possible, the Medical Card system should be made simpler and more explicit, and there
needs to be a comprehensive suite of communication and education materials to assist
individuals and healthcare professionals with the Medical Card application process and the
concept of renewal.
10. Non-medical benefits should be uncoupled from Medical Cards. Access to these non-medical
benefits should, however, remain as a means-tested support, but should not be an automatic
entitlement determined by an individual’s Medical Card status.
11. Access to primary care services (physiotherapy, occupational therapy, speech and language
therapy, public health nursing etc.) should be consistent across the country. Prioritisation
should be on the basis of clinical need – independent of the possession of a Medical Card –
defined after triage into categories of urgent or routine, and thereafter seen in chronological
order within these categories.
12. An individual’s Medical Card status should not be the sole qualifying criterion for access to aids
and appliances.
13. For individuals awarded a Medical Card incorporating ‘discretion’, the renewal process needs
to be handled with a greater degree of sensitivity.
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14. As a working principle, discretionary Medical Cards should only be provided to the individual
with the index condition, and not to the entire family.
15. If a discretionary Medical Card award involves any terminal or life-limiting condition, such as
motor neurone disease, then it should be granted for the remainder of life, and should not
require the individual or their family to undergo a standard review process every three years.
16. Society’s desire to exercise a more compassionate and supportive approach for those with a
combination of financial and/or medical hardship should be addressed by extending the
discretionary decision-making process beyond financial hardship to include an assessment of
the burden of a medical condition(s).
17. The general population should be involved in deliberating on the ethical and social issues
arising from access to healthcare in the context of finite resources.
18. A new Strategic Clinical Advisory Group should be incorporated into the PCRS governance
structure, with broad and experienced clinical, lay and administrative representation and
access to expert opinions when required. It is the view of the Expert Panel that this is required
in order to give clinical oversight and guidance to the operation of a more compassionate and
trusted Medical Card system which can strive to ensure that the relatively small percentage of
cases requiring the recognition of the burden of a medical condition(s), over and above
financial hardship, can be accommodated.
19. The initial work programme for the Strategic Clinical Advisory Group should firstly address the
development of a strategic framework for assessment and measurement of the burden of
disease; secondly, the development of appropriate operational guidelines for Medical
Assessors and Decision Officers and, thirdly, the development of appropriate key performance
indicators (KPIs) to support clinical oversight and performance assurance.
20. The significant challenges to be faced in extending the discretionary decision to include an
assessment of the burden of a medical condition(s) must be acknowledged by all. These
include the fact that professional judgement in the assessment of medical hardship can never
be completely objective, fully transparent and totally reproducible; the methodology to
underpin an enhanced discretionary process requires an options appraisal of existing
measurement and disability comparators, and proxy measures of the burden of disease
including healthcare consumption; a realistic timeframe to examine the feasibility and costing
of such a process; and finally, the additional resourcing that will be required to increase clinical
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assessment capacity, including doctors, nurses and allied health professionals, in order to
provide a greater degree of scrutiny and personalised clinical judgement.
21. In terms of maximising population health gain, a priority for the health service should be to
use the preceding recommendations as a stepping stone to the implementation of the first
phase of the Government’s Primary Care reform programme, providing free GP care for all,
with the aim of further ensuring universal access to the full spectrum of Primary Care Services
as a matter of course and thereby aligning the health service in Ireland with health systems in
other EU Member States.
22. An annual report of the implementation status of each of the recommendations contained in
this report should be presented by the HSE National Director of Primary Care to the Director
General of the HSE.
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1. INTRODUCTION
1.1 Ideally, a national health service should be free at the point of use, meet the clinical needs of
everyone, be comprehensive and integrated in the services it delivers, and provide support,
education and care that is evidence based and outcome validated. This is a tall order for any
national government and is probably not fully achievable.
1.2 The General Medical Service (GMS) scheme governs access to Medical Cards in Ireland.
Eligibility criteria are set out in legislation and have traditionally been based on income
thresholds since the 19th
century, when Poor Law bodies took over the dispensary system and
provided free services for those who were unable to pay for them. Although there have been
various amendments and reforms of the system since that time, the basic premise has
remained the same i.e. that the State has an obligation to provide general medical services for
those who are unable to pay for them through their own means. In addition to setting specific
income thresholds for specified categories of persons who are eligible to receive listed
services, there has also traditionally always been a discretion vested in the Local Health
Offices/Health Boards to grant Medical Cards in cases of particular hardship to those who
would otherwise be ineligible.
1.3 Up to July 2011, the issuance of Medical Cards was administered in approximately 100 Local
Health Offices, reflecting the former health board structure. A key risk in any such
decentralised administration system is unaccountable inconsistency or variability between
regions in the application of eligibility rules. While the Medical Card Scheme had been the
basis for the delivery of the majority of primary care services in Ireland for over 40 years, there
was clear evidence that assessment for eligibility for Medical Cards was not consistent
between the 100 Local Health Offices conducting the reviews, with some card holders granted
Medical Cards for long periods, in some cases up to 20 years.
1.4 In consultation with the Department of Health, the HSE decided that fundamental change in
the administration of the scheme was required if the inefficiency and lack of transparency and
consistency was to be addressed. Since 1 July 2011, card issuance has been managed centrally
within the HSE Primary Care Reimbursement Service (PCRS). The objective of the centralisation
process was to provide for a single, uniform system for Medical Card applications and
renewals, replacing the different systems previously operated in the Local Health Offices;
streamline work processes and implement process improvements, resulting in more efficient
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processing; reduce the number of staff required to process applications and renewals;
improve customer services and over time; ensure a more accountable and better managed
Medical Card processing service.
1.5 There is evidence that the wide variation in assessment for Medical Card eligibility has
reduced, and that an appropriate level of transparency, consistency and equity is appearing.
See Figure 1.
Figure 1 Variation in assessment of Medical Card eligibility before and after administrative
centralisation
1.6 Although the centralisation of administration of Medical Card eligibility assessment has
allowed the introduction of a uniform system for assessment of eligibility, it was somewhat
inevitable that such a large system, and indeed cultural change over a relatively short time
period, would result in a certain level of non-renewal amongst Medical Card holders. The issue
of Medical Cards has come to the fore this year, triggered in part, it appears, by the level of
non-renewal amongst Medical Card holders, and in particular the non-renewal of Medical
Cards that had been issued on the basis of discretion. This has caused significant upset and
disquiet.
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1.7 In the context of discretionary Medical Cards, the upset and disquiet has been exacerbated by
an inherent level of massive variability in their award across the 26 counties, ranging from 3-
12/100,000 population to 39-53/100,000 population.1
1.8 In its report to the Committee of Public Accounts in June 20142 the HSE explained that planned
expenditure (2014) in the delivery of primary care services across 12 community health
schemes, including the Medical Card Scheme, to the entire population would amount to
approximately €2.4 billion, involving approximately 80 million transactions delivered to more
than 3.4 million eligible persons.
1.9 The scale of costs within the Medical Card and Primary Care schemes, as well as the volume of
associated transactions, mean that there are areas of risk that need to be managed and
controlled. The Comptroller and Auditor General has already reported that the evidence
suggests there is a significant level of excess payment in the Medical Card system and the HSE
should conduct reviews of random samples of Medical Card holders on an annual basis.3 In the
main, excess payment (i.e. ineligibility) arises as a result of changes in the card holder’s
circumstances over the validity period of the card.
1.10 Legislation enacted in March 2013 provides for the furnishing of data by the Department of
Social Protection and the Revenue Commissioners to the HSE.
1.11 The HSE has implemented a series of control options which comprise a review upon expiration
of the defined eligibility period; risk-based reviews based on specific criteria such as inactive
cards or where information from other Departments4 or bodies indicate that the Medical Card
should be reviewed; random review; use of the Death Events Notification System (DEPS),
which identifies people who are deceased.
1.12 In response to the public disquiet as to the legitimacy and authority of the Medical Card
system, a Government decision was taken (July 2014) to restore discretionary Medical Cards to
approximately 13,300 people. In addition, the Director General of the HSE commissioned an
Expert Panel to attempt to list conditions in priority order as to their eligibility for Medical
Cards; he also commissioned a Review of the HSE PCRS by Prospectus and Deloitte.
1 Personal communication, July 2014. HSE, Office of National Director of Primary Care
2 HSE Report to the Committee of Public Accounts on 12 June 2014
3 The Comptroller and Auditor General’s Report on the accounts of the public services 2012 (published
September 2013) 4 Section 8 Health (Alteration of criteria for eligibility) Act 2013. Legislation enacted in March 2013 provides for
the furnishing of data by the Department of Social Protection and the Revenue Commissioners to the HSE.
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1.13 It should be noted that the Government announced in 2013 (Budget Day) that all children
under the age of six years would be entitled to GP Visit Cards.
1.14 The Terms of Reference of the Expert Panel were:
1.14.1 To advise on the appropriate approach to identify and examine medical conditions,
the treatment and management of which would benefit most from access to services
currently only available to persons with full Medical Card eligibility.
1.14.2 To devise a framework, incorporating specific criteria which will prioritise medical
conditions in terms of the degree of health benefit to the person with the medical
condition.
1.14.3 To apply objective medical and scientific evidence during the course of all
deliberations, conclusions and recommendations.
1.14.4 To seek advice of other relevant experts as required.
1.14.5 To take into consideration the views of patients, the public and patient
representative/advocacy groups, in order to reflect the patient perspective.
1.14.6 Advise on the timeframe for any periodic review of the list of medical conditions
proposed.
1.14.7 Advise on the appropriate approach to meet the needs of individual patients with
medical conditions of a transient nature.
1.14.8 Provide an initial report to the Director General (DG) to include a list of medical
conditions for the DG to present to the Minister for Health and Government.
1.14.9 Report to the Budget Impact Analysis Group and to the Director General.
1.15 The Expert Panel, although primarily charged with attempting to list medical conditions as to
their suitability for Medical Card, were of the view that this would inevitably result in providing
their perspective and commentary on the operation of the Medical Card system. Because of
the sheer complexity of the issues involved, the panel believed that an ethical commentary
and perspective would provide an important and valuable framework to guide their
deliberations, conclusions and recommendations. The Expert Panel’s work has also been
guided and referenced against the experience in other EU healthcare systems. The Expert
Panel was particularly determined to ensure that the views of patients, the public and patient
representative/advocacy groups would play a central role in their work.
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Medical Cards and media coverage (January-June 2014)
1.16 The Expert Panel examined media coverage of the discretionary Medical Card issue as it
evolved over the course of the first six months of 2014.5
1.17 Between 1 January and 30 June 2014, a total of 772 articles in the Republic of Ireland press
were recorded on the issue of discretionary Medical Cards; the heaviest volumes of articles
were recorded in May and June, with 330 and 333 articles respectively (See Figure 2). One-
third of all reportage on the matter (equating to 254 articles) referenced a particular illness or
condition. May was the heaviest month for references to illnesses or conditions that could be
impacted by the loss of discretionary Medical Cards, with 129 articles noted.
Figure 2 Trend in media coverage of medical cards (Jan-June 2014)
5 Kantar Media was commissioned to undertake an analysis of media coverage on behalf of the Expert Panel,
covering the period January-June 2014.
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1.18 Down syndrome was by far the most prevailing condition to resonate in the press over the
timeframe. References to cancer-related illnesses also substantially permeated the press
coverage. See Table 1.
Table 1 Illness and conditions associated with media coverage (January-June 2014)
Reported illness/condition Volume of
articles
Down syndrome 106
Cancer 81
Arthritis 29
Leukaemia 29
Cerebral palsy 26
Motor neurone disease 20
Kidneys/dialysis 19
Multiple sclerosis 12
Epilepsy 9
Mowat-Wilson syndrome 9
Asthma 8
Wiedemann-Steiner syndrome 4
KCNQ 3
Narcolepsy 3
Lung transplants 2
Severe global development delay 1
STXBP1 1
Immunodeficiency conditions 1
Parkinson’s disease 1
Spina bifida 1
Filamin-A gene disorder 1
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1.19 Multiple charities and associations obtained citations in the press in relation to this issue, with
the most prolific being Our Children’s Health, the Jack & Jill Children’s Foundation, Irish Cancer
Society and Down Syndrome Ireland (Figure 3).
Figure 3 Charities and associations citations in media coverage (January-June 2014)
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2. ETHICAL PERSPECTIVE
Relevance of ethics
2.1 Where resources are limited and it is impossible or impracticable to provide universal services,
any decision to reallocate resources within the public health system, or to allocate services to
one group rather than another, is a decision that must be open to strict scrutiny and
accountability. The basic premise of Irish society is that every citizen has fundamental
constitutional rights such as the right to life and the right to education, but enforceability of
those rights may be contingent on the availability of the necessary resources. When resources
are limited, corresponding rights to those resources also become limited. The difficulty lies in
trying to ensure fairness and ethical justice in the rationing process. Many criteria play a role in
decision-making in this context. As follows:
• The societal wish to maximise general population health
• Distribution of health in the population and redressing inequities; many societies may
wish to prioritise vulnerable population groups, such as those in lower socio-economic
groups, those with chronic conditions, children, pregnant women and the elderly.
• Specific societal preferences that target preventative over curative treatments, or the
provision of acute care in life-threatening situations
• Budgetary constraints and the costs of implementation
• Political criteria such as the influence of interest groups and legacy issues.
2.2 In making such difficult decisions, ethical principles can come into conflict and it becomes
necessary to balance competing concerns. There is no national or international consensus on
the correct approach to this balancing exercise.6 The emphasis in the literature on this issue is
on ensuring that the decision-making process itself is fair, open and inclusive of all
perspectives. Therefore it is important that the decision-maker is as transparent as possible in
relation to the ethical stance taken and the values underpinning the decision.
6 The ethical principles adopted by Healthy Ireland in its Framework for Improved Health and Wellbeing 2013-
2025 are Equity, Fairness, Proportionality, Openness and Accountability, Solidarity, and Sustainability,
http://www.hse.ie/eng/services/publications/corporate/hieng.pdf
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Principalism
2.3 There are a number of ethical approaches that may be taken to the analysis of healthcare
decision-making. These include casuistry (solving cases by referring to paradigmatic cases for
which an undisputed solution has already been found), coherence analysis (reflecting on the
consistency of ethical arguments or theories without prescribing which arguments are prima
facie relevant), interactive (inter-subjective consensus on problematic issues reached through
discourse involving relevant stakeholders), or principalism (analytical framework based on
common moral principles shared in society). The latter has recognised advantages in that it
provides a comprehensive normative framework for ethical analysis rather than just a
procedural approach. The application of biomedical principles, in particular those developed
by Beauchamp and Childress,7 is one of the most frequently used approaches to resolving
ethical dilemmas in healthcare.
The Four Principles approach devised by Beauchamp and Childress are as follows:
• Respect for persons (autonomy, ensuring patient understanding, voluntariness, decision-
making capacity)
• Beneficence (balancing benefits and harm: risks/costs)
• Non-maleficence (the minimisation of harm to others)
• Justice (the fair distribution of benefits and burdens).
2.4 Although it does not feature in the Four Principles approach outlined above, another
important ethical value is that of compassion, which demands that attention be paid to the
effects of health inequalities on individuals and families. Inequalities in health are differences
in health status or in the distribution of health determinants between different population
groups due to the conditions in which people are born, grow, live, work and age. As pointed
out by Healthy Ireland, “there is an uneven distribution of the risk factors associated with
many chronic diseases, with the burden borne disproportionately by those in the lower socio-
economic groups. People with higher socio-economic position in society have a greater array
of life chances, more opportunities to lead a more fulfilling life and tend to have better
health.”8
7 Beauchamp and Childress, Principles of Biomedical Ethics (1979), now in its 7
th ed.
8 Healthy Ireland, A Framework for Improved Health and Wellbeing 2013-2025 at page 45
http://www.hse.ie/eng/services/publications/corporate/hieng.pdf
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2.5 These ethical principles are prima facie binding, meaning that they are always important in
every situation, but they are not absolute and may come into conflict with each other. The
principles must always be viewed in the context of the specific matter under consideration,
and balanced with each other. Balancing principles can be challenging, but it is worth
considering that a principle should only be overridden if better reasons can be provided for
acting on an overriding principle, and the infringement must be commensurate with achieving
the primary goal, negative effects of the infringement are minimised, and the decision is
reached impartially.
2.5.1 Respect for persons – This includes acknowledging a person’s right to make choices, to
hold views, and to take actions based on personal values and beliefs. It is often
described as respect for autonomy, which literally means self-rule, in other words
making one’s own deliberate decisions. In the medical context, respect for autonomy
is of vital significance in ensuring that patients are informed about their choices and
asked to make their own decisions about their healthcare. It requires doctors to seek
informed consent from patients before any treatment or intervention (except in cases
of incapacity or medical emergency). It also requires patient confidentiality to be
maintained, appropriate behaviour to be practised and good communication methods
to be used between patients and healthcare professionals.
2.5.2 Beneficence and non-maleficence – The ultimate aim in healthcare is to produce net
benefit over harm, while recognising that inevitably some risk of harm may exist when
any medical intervention takes place. Beneficence is the traditional Hippocratic duty to
prioritise patients’ best interests, while non-maleficence is the duty not to cause harm
or risk of harm to patients. These duties mean, for example, that those who treat
patients must be appropriately qualified, as otherwise the risk of causing harm
becomes disproportionate. Healthcare professions therefore undertake to provide
appropriate training and education to prospective and current practitioners in order to
ensure adequate protection of patients.
2.5.3 Justice – The principle of justice could be described as the moral obligation to act on
the basis of fair adjudication between competing claims. As such, it is linked to
fairness, entitlement and equality. In healthcare ethics, this can be subdivided into
three categories: fair distribution of scarce resources (distributive justice), respect for
people’s rights (rights-based justice) and respect for morally acceptable laws (legal
21
justice).9 In the context of the allocation of resources, conflicts exist between several
common moral concerns: to provide sufficient healthcare to meet the needs of all who
need it; when this is impossible, to distribute healthcare resources in proportion to the
extent of people's needs for healthcare; to allow healthcare workers to give priority to
the needs of their patients; to provide equal access to healthcare; to allow people as
much choice as possible in selecting their healthcare; to maximise the benefits
produced by the available resources; to respect the autonomy of the people who
provide those resources and thus limit the cost to taxpayers and subscribers to health
insurance schemes. All these criteria for justly allocating healthcare resources can be
morally justified but not all can be fully met simultaneously.10
Justice in access to healthcare services
2.6 Clearly, good health is vitally important. We all desire it for ourselves, our loved ones, and
indeed for everyone. Few would dispute that access to essential healthcare should not hinge
on one’s ability to pay. However, “at its most basic level, it is literally impossible for
government to guarantee good health to its citizens.”11
…“Because of resource scarcity, access
to healthcare and related technologies in practice hinges not on legal requirements, but on
government budget decisions and, at the private level, on clinical judgements of health
professionals and the incomes of individual patients. In keeping with their responsibility to
provide for the general welfare, governments have much of the responsibility for defining
public health objectives for the whole society and providing the resources to achieve them.
Those determinations always involve negotiation, trade-offs, and the balancing of interests.”12
2.7 In relation to the issue of access to or allocation of healthcare services, the principle of justice
is one of the most important bioethical principles in this balancing of interests and has been
addressed in bioethics literature since the 1980s. If we accept that the health system must be
sustainable13
and that it is impossible for any health system to provide everything for
everyone, then setting limits on expenditure of shared societal resources is ethically required
and must be done in a just, transparent and compassionate way.
9 R Gillon “Medical ethics: four principles plus attention to scope” (1994) BMJ 309:184 10 Gillon, note 4 11
Timothy Goodman “Is there a right to health?” (2005) Journal of Medicine and Philosophy 30:643-662 12
Goodman note 6 at 655 13
Healthy Ireland, a Framework for Improved Health and Wellbeing 2013-2025, Appendix 2
http://www.hse.ie/eng/services/publications/corporate/hieng.pdf
22
2.8 Rationing14
is the controlled allocation of some scarce resource or goods. It implies that limits
are placed on its availability. In healthcare this applies to treatments, services,
pharmaceuticals, medical procedures and so on. When healthcare resources are rationed,
patients may be restricted to certain treatments or placed on waiting lists for treatments. It
means that someone somewhere has made a decision about the limits of what is provided or
how it is provided, i.e. a priority-setting decision.15
Although rationing of healthcare resources
sounds like an unethical proposition, as it interferes with individual choices and values, it is
inevitable in all healthcare systems around the world. Indeed, there are those who argue that
healthcare rationing is not only necessary but also desirable. “The careful rationing of health
care is one of the factors that make a health care system work well. The best health care
systems in the world do it.”16
2.9 Hard ethical choices are sometimes masked in clinical or technical terms, as the idea of
rationing is unpalatable, unpopular and not politically correct, since it means in reality that
some people who may benefit from healthcare may have to do without it. However, it is
important to acknowledge that rationing is not limited to State-run or sponsored public health
systems, it also takes place in private health insurance and in the most affluent of societies.
When the Government decides which drugs to subsidise, it is engaged in rationing; when it
decides where to build a new hospital, it is engaged in rationing; when it introduces a cancer
screening programme it is engaged in rationing because as a result of those priority-setting
decisions, other drugs, citizens and patients will not be funded. Private insurers carry out the
same exercises by loading premiums on new entrants with pre-existing conditions, or by
agreeing to only fund certain treatments. It is inevitable that some patients will be
disadvantaged by the limits that are set in either the public or the private healthcare system.
What is crucially important here is that the priority-setting decisions must be reached fairly
and efficiently, so that they can be morally justified.
2.10 As members of society we are still feeling our way even at the level of defining what the
competing moral concerns of justice are. Gillon says we must be particularly wary of
apparently simple solutions to what have been perceived as highly complex problems for at
least 2,500 years.17
For example, he refers to populist solutions in distributive justice such as
have occurred in Oregon in the United States (see below), and technical and simplistic
14
Indeed, the word rationing itself is usually avoided, as it raises memories of war-time scarcity and poverty,
but it is arguably a more honest and accurate description of the reality of healthcare systems worldwide. 15
Bognar and Hirose, The ethics of health care rationing (Routledge Press 2014) page 1 16
Bognar and Hirose note 9 at 2 17
Gillon, note 4
23
economic solutions such as the system of costed quality-adjusted life years (QALYs) which are
tempting in their definitiveness and simplicity; they fail, however, to give value to the wide
range of other potentially relevant moral concerns.
How do we set priorities ethically?
2.11 Disease and disability, by impairing normal functioning, restrict the range of opportunities
open to individuals. Healthcare is special because it protects or tries to restore normal
functioning, which in turn protects the range of opportunities open to individuals. Healthcare
thus makes a distinct but limited contribution to the protection of equality of opportunity; it
preserves for people the ability to participate in the political, social and economic life of their
society and sustains them as fully participating citizens.18
However, although the idea of
rationing health services causes political and social discomfort, the reality is that the notion
that a State could provide every single intervention that holds even the smallest possibility of
clinical benefit to every citizen is financially untenable.19
The argument that healthcare should
contribute to equality of opportunity does not provide us with the means by which to address
highly contested issues of how to distribute medical goods and services fairly.
2.12 There are various approaches in moral theory that one might take to this issue: libertarianism,
utilitarianism, egalitarianism etc. Nearly all appear to take the view that just societies should
provide all their members with guaranteed access to at least a decent minimum of healthcare,
although there is little consensus on what the decent minimum entails.20
Acknowledging
therefore that some rationing/priority-setting/allocation decisions must be made, a fair
process must be established by which to make such decisions.
The Oregon example
2.13 An often-quoted process of healthcare allocation decision-making is the Oregon plan, which
took place in the late 1980s following a public outcry after the death of a seven-year-old boy
whose bone marrow transplant, which would have cost €100,000, was not covered by
Medicaid. The State of Oregon realised that it had to balance costs, benefits and access in the
face of scarcity of resources. Either it had to limit the Medicaid programme to the most cost-
effective services, or it had to deny healthcare to many people. The State Government
18 Norman Daniels, “Justice, Health and Healthcare” (2001) American Journal of Bioethics Vol. 1 No. 2 19
Samia Hurst and Marion Danis “A framework for rationing by clinical judgement” Kennedy Institute of Ethics
Journal (2007) Vol 17, No.3, 247-266 20
Madison Powers and Ruth Faden, “Inequalities in Health, Inequalities in Health Care: Four Generations of
Discussion about Justice and Cost-Effectiveness Analysis” (2000) Kennedy Institute of Ethics Journal Vol. 10,
No.2, 109-127 at 111
24
decided to develop an open and transparent process for citizens to agree on a list of medical
services that would be covered by its Medicaid programme for those below a specified income
level. A working group was established and agreed on three important principles:
• Access to a basic level of care must be universal.
• Society is responsible for financing care for poor people.
• A basic level of care must be defined through a public process.
2.14 A panel of experts known as the Health Services Commission was tasked with formulating a
list following extensive public consultation which was declared to be the world’s first
prioritised list of health services.21
The first list, which was based on a methodology of cost-
benefit analysis, yielded some peculiarities, such as possibly covering tooth caps, but not
surgery for emergent appendicitis. The plan was subject to much criticism, due to these
anomalies and there was also opposition to the plan on the grounds that it discriminated
against people with disabilities. The Commission revised the plan to take these considerations
into account, with the result that cost effectiveness was relegated to the back seat.22
2.15 As an example of the commission’s work in rebalancing competing claims, the highest-priority
categories 1 through 6 subsequently encompassed services such as the “birth of a child and
maternal care” (Category 1); “preventive care;” and “life-threatening diseases,” each with
many line items in the category, whereas lower-ranked categories included non-fatal, self-
limiting, elective, or inconsequential conditions and interventions. The Oregon Health Plan
was finally accepted in 1993. Although in many ways an imperfect method, many advocates
have noted the importance of the list from an ethical point of view in attempting to develop a
fair and transparent consultative public process for prioritising medical services through its
laws and regulations.
The National Health Service (UK)
2.16 Another example of how rationing decisions are made in other jurisdictions can be seen in the
model adopted in the UK where healthcare is provided by the publicly funded National Health
Service (NHS). In England and Wales, decisions relating to access to healthcare are
decentralised and services are organised by regional trusts, with the result that there are
inequalities between different areas, known as the postcode lottery.23
Trusts make their own
21
http://www.oregon.gov/oha/healthplan/pages/priorlist.aspx 22
Bognar and Hirose, note 10 at 61 23
Bognar and Hirose, note 10, 63-65
25
decisions about spending and coverage, so a patient may not be covered for an intervention
that another patient living in a different area would be covered for.
2.17 To reduce this inequity, the government asked the National Institute for Clinical Excellence
(NICE) to draw up guidelines for coverage and spending decisions. Its guidelines are based on
cost effectiveness analysis, measured by QALYs,24
of new medical technologies and treatments
and it has not undertaken a systematic review of all medical technologies and services. NICE
also instituted Citizen Councils, comprised of representatives of the general population rather
than experts in healthcare, to deliberate on the ethical and social issues raised by its
guidelines. In common with the Oregon Health Plan, this also demonstrates the importance
and value of a fair and transparent consultative public process for prioritising payment for
medical services.
Conclusion
2.18 Every member of society must have an adequate array of core healthcare benefits; every
member of society deserves an adequate level of protection from illness and avoidable pain
and suffering related to health conditions. However, this does not mean access to every
potentially useful health service, as there are links between access, cost and quality that
cannot be ignored. These interconnections must be comprehensively considered, as otherwise
they may result in ethical difficulties in terms of reduced overall access, or unacceptable
effects on cost and quality.
2.19 The contents and limits must be established through an ethical process – setting limits or
‘rationing’ is difficult, but can be achieved ethically if the following five principles are taken
into account:25
1. Transparency – the priority-setting process should be transparent to those affected.
2. Participatory – the process should involve all stakeholders in the design of the process.
3. Equity and consistency – it should result in similar decisions for those in similar
circumstances.
4. Sensitivity to value – it should take into account net health outcomes of services and the
required resources.
5. Compassion – it should be flexible, responsive to individual values and attentive to the
most vulnerable individuals and those with critical needs.
24
Quality-adjusted life years 25
Ethical Force program of the American Medical Association: http://www.ama-assn.org/ama/pub/physician-
resources/medical-ethics/the-ethical-force-program/fair-health-care-coverage.page
26
3. THE CURRENT MEDICAL CARD SYSTEM IN IRELAND
Legislation
3.1 The main legislation on entitlement to Medical Cards is Section 45 of the Health Act 1970. This
has been amended a number of times.
Section 45, as amended, provides:
(1) A person in either of the following categories shall have full eligibility for the services
under this Part—
(a) adult persons, who in the opinion of the Health Service Executive, are unable
without undue hardship to arrange general practitioner medical and surgical
services for themselves and their dependants,
(b) dependants of the persons referred to in paragraph (a).
(2) In deciding whether or not a person comes within the category mentioned in subsection
(1) (a), the Health Service Executive shall have regard to the person’s overall financial
situation (including the means of the spouse, if any, of that person in addition to the
person’s own means) in view of the person’s reasonable expenditure in relation to
himself or herself and his or her dependants, if any.
3.2 Of note, the legislation governing the awarding of Medical Cards does not mention the phrase
Medical Cards. Instead, it describes people who have full eligibility for health services.
3.3 The health service can exercise discretion when a person does not qualify for a Medical Card
under Section 45 (1), but where circumstances would merit the awarding of a card.
Section 45, as amended, provides:
(7) Any person who is not in either of the categories mentioned in subsection (1) but who, in
relation to a particular service which is available to persons with full eligibility, is
considered by the chief executive officer of the appropriate health board to be unable,
without undue hardship, to provide that service for himself or his dependants shall, in
relation to that service, be deemed to be a person with full eligibility.
3.4 The only criterion used to determine whether or not to provide a Medical Card is based is
whether the individual would be unable to provide that service for himself and his dependants
without undue hardship. The Act does not provide for further criteria upon which the health
service can evaluate what amounts to undue hardship.
27
3.5 The exercise of discretion provided for in Section 45 (7) can only be determined using
professional judgement and expertise. Each case must be determined on its merits, using the
criteria that are appropriate in each case to decide on the issue of undue hardship.
3.6 Any setting of an exhaustive list of criteria or measuring of thresholds might amount to an
unlawful restriction of the health service’s statutory discretion. As a result, flexibility is
required in order to properly assess each case on its merits and evaluate the injustice to the
individual against the tangible public benefit if a card is to be withheld.
3.7 Entitlement to a GP Visit Card is governed by Section 58 of the Health Act 1970 (as amended
by the Health (Amendment) Act 2005).
Section 58 of the Health Act, 1970, as amended, provides:
(1) The Health Service Executive shall make available without charge a general practitioner
medical and surgical service for a person in any of the following categories –
(a) persons with full eligibility
(b) adult persons with limited eligibility for whom, in the opinion of the Health Service
Executive, and notwithstanding that they do not come within the category mentioned in
section 45(1)(a), it would be unduly burdensome to arrange general practitioner medical
and surgical services for themselves and their dependants, and
(c) dependants who are ordinarily resident in the State of the persons referred to in
paragraph (b).
(2) In deciding whether or not a person comes within the category mentioned in subsection (1)
(b), the Health Service Executive shall have regard to the person’s overall financial situation
(including the means of the spouse26
, if any, of that person in addition to the person’s own
means) in view of the person’s reasonable expenditure in relation to himself or herself and his
or her dependants, if any.
26 The Revenue Commissioners are of the view [related to Data Protection] that it cannot, under the current
legislative arrangements, supply Revenue information to the HSE in relation to spouses.
28
Medical Card application process
3.8 An individual may be entitled to a Medical Card if they are ordinarily resident in Ireland.
Entitlement is decided by the Health Service Executive (HSE) and is mainly based on legislation
as described above.
3.9 If an individual does not qualify for a Medical Card, then they may qualify for a GP Visit Card.
This is also based on legislation, as described above.
3.10 The majority of Medical Cards are awarded on the basis of a means test together with an
examination of an individual’s medical and social circumstances. Every new application can go
through four steps to determine their eligibility for a Medical Card or GP Visit Card.
3.10.1 Step 1: If an individual’s assessed income is less than the income guideline ceiling,
then they qualify for a Medical Card.
3.10.2 Step 2: If an individual’s income is above the relevant guideline, then their medical and
social circumstances can be taken into account to establish whether undue hardship
would occur if they did not get a card.
3.10.3 Step 3: If an individual does not qualify for a Medical Card, they are then automatically
assessed for a GP Visit Card. The income guideline ceilings are approximately 50%
higher than those for a ‘regular’ Medical Card. If an individual’s assessed income is less
than the guideline, then they qualify for a GP Visit Card.
3.10.4 Step 4: If an individual’s income is above the guidelines for a GP Visit Card, then again
the medical and social circumstances are taken into account to see if it would be
unduly burdensome for that individual to have to meet the GP costs themselves.
3.11 Current legislation requires that both an individual’s income and expenditure (i.e. their overall
financial situation) must be taken into account during the assessment process. ‘Undue
hardship’ and ‘unduly burdensome’ do not appear to have significantly different meanings in
the assessment process. For people aged over 70, applications are assessed on gross income
at higher thresholds and expenditure is not taken into account. However, these individuals
have the option of applying under the general Medical Card scheme, where the thresholds set
are lower, and expenditure is taken into account in this process.
29
3.11.1 The assessment process27
examines the individual’s ability to meet the essential
costs associated with maintenance of employment; provision of reasonable housing;
provision of appropriate nurturing and care for children or dependants; provision of
adequate heating, nutrition and clothing; coping with exceptional personal and
financial burdens arising from medical or social circumstances.
3.11.2 Factors that are accounted for during this process include the illness or medical
circumstances that result in financial hardship; the cost to the individual of providing
general medical and surgical services; medical, nursing and dental treatment;
physiotherapy; speech and language therapy; transport to hospitals and clinics;
medical aids and appliances; social medical circumstances (e.g. addictions such as
drink, drugs and gambling) and poor money management and social deprivation,
including poor home management.
3.11.3 With the individual’s consent the assessment process can also include advice from a
wide variety of sources including the applicant. In making the decision the PCRS staff
member does, in general, with the consent of the individual, liaise with the
applicant's doctors, allied health professionals and others.1
3.12 Medical Cards (or GP Visit Cards) awarded after an assessment of undue hardship or undue
burden have become associated with the phrase ‘discretionary Medical Cards’. The
definition of discretionary is misunderstood and undoubtedly a cause of confusion. There is
no difference between Medical Cards (or GP Visit cards) awarded purely on the basis of
income being below the guidelines and Medical Cards (or GP Visit Cards) awarded after an
assessment of undue hardship or undue burden.
3.13 Discretion is not a stand-alone exercise open to some and not to others; rather, it is an
integral part of the assessment process for a Medical Card application.
Medical Card – Amendments by GPs
3.14 In February 2012, the HSE entered an agreement with the Irish Medical Organisation (IMO)
whereby GPs, in certain circumstances, can make amendments to the Medical Card database
by temporarily extending card eligibility for four months, or by restoring eligibility to a patient
27
HSE Medical Card/GP Visit Card National Assessment Guidelines (January 2014)
30
who has had their eligibility removed due to not responding to renewal notices from the
HSE.28
3.15 In most cases where a GP amends the Medical Card database, third party verification is then
sought from the family or a nursing home, or the HSE initiates a review of eligibility.
3.16 In 2012, GPs reinstated eligibility in 800 cases where they were of the opinion that eligibility
had been removed in circumstances where the applicant had not responded to renewal
notices, and eligibility should be restored.
3.17 The database was amended in 200 cases where GPs were of the opinion that it was a sensitive
case. In such cases, eligibility is extended for a year. No third party verification is completed
routinely, since by definition the purpose of this action is to prevent correspondence being
issued to individuals not in a position to deal with such administration.
Emergency Medical Cards
3.18 An emergency Medical Card, valid for six months, can be issued within 24 hours of a doctor’s
report being made available in a number of circumstances, including for any patient who is in
palliative care and is terminally ill; a homeless person in need of urgent medical care; a person
with a serious medical condition in need of urgent medical care; a foster child in need of
urgent medical care; an asylum seeker with a serious medical condition in need of urgent
medical care.
3.19 Where a GP or consultant certifies that there is a terminal illness and the applicant is nearing
the end stage of life, the nature of the terminal illness is not a deciding factor in the issue of a
Medical Card, and no assessment of means applies.
Others with Medical Card entitlements
3.20 People aged 70 years and over
The Medical Card Scheme for people aged 70 years and over was revised with effect from 1
January 2014, resulting in changes to the qualifying gross income thresholds for Medical Card
eligibility.
28
Comptroller and Auditor General’s Report on the accounts of the public services 2012 (published September
2013)
31
3.21 Thalidomide and symphysiotomy
Any individual affected by the drug Thalidomide, or survivors of symphysiotomy, are entitled
to a Medical Card, regardless of means. This arrangement is not on a statutory basis.
3.22 Retention of Medical Cards
At present, if an individual has a Medical Card and they take up employment or participate in
a back-to-work scheme, then they may retain the Medical Card (for themselves and their
dependants) for three years after their change of circumstances, even in the event that they
do not continue to meet the means test or undue hardship requirements. This arrangement is
not on a statutory basis. It was announced in Budget 2014 that this system would be changed
via legislation to provide for an arrangement whereby such an individual would be given a GP
Visit Card instead of a Medical Card.
3.23 Hepatitis C/HIV
Any patient who contracted Hepatitis C or HIV from the use of human immunoglobulin-anti D
blood products is entitled to the same services as a Medical Card holder, and is also entitled to
other services including home nursing, home help, physiotherapy, counselling services and
such other services as may be prescribed by the Minister for Health. This is provided for under
separate legislation – the Health (Amendment) Act 1996 whereby the individual is entitled to a
Health (Amendment) Act Card rather than a standard Medical Card.
3.24 EU regulations
Under EU Regulation 1408/71 each EU Member State is responsible for its own social security
system and health service provision, and makes its own decision on the levels of social
security and healthcare benefits it offers. The broad principle of the Regulations is that, if an
individual moves from one country to another, then they are entitled to avail of health
services in their new country on the same basis as if they were living in their home country. In
practice, this means that people who are ordinarily resident in Ireland and who are covered by
the EU Regulations are entitled to Medical Cards in Ireland.
32
Medical Card Benefits
Medical benefits
3.25 The main services to which Medical Card holders are entitled free of charge include:
• GP/family doctor services
• Approved prescribed drugs and medicines (subject to prescription charges)
• In-patient and day-case treatment in public beds in public hospitals
• Out-patient services in public hospitals
• Medical and midwifery care for mothers and infants
• A maternity cash grant for each child born
• Dental, ophthalmic and aural services.
3.26 While Medical Card holders are entitled to get approved prescribed drugs and medicines free
of charge, they do nonetheless have to pay a prescription charge, which is currently €2.50 for
each item dispensed, subject to a maximum of €25 a month for an individual or a family.
3.27 A GP Visit Card entitles the holder to GP/family doctor services free of charge.
Non-medical benefits
3.28 Medical Card holders whose income is more than €10,036 pay the Universal Social Charge
(USC) but at a maximum rate of 4%.
3.29 The FOI application fee for a Medical Card holder in relation to non-personal information is
€10 (standard fee is €15).
3.30 Medical Card holders are eligible for reduced charges for appeals under the Access to
Information on the Environment (AIE) regulations.
3.31 Medical Card holder is an eligibility criterion for Higher Education Access Route (HEAR), a
college and university admissions scheme that offers places on reduced points and extra
college support to school leavers from socio-economically disadvantaged backgrounds.
3.32 Medical Card holders may also be exempt from paying school transport charges in publicly
funded second-level schools.
3.33 Medical Card holders may also be exempt from paying State exam fees in publicly funded
second-level schools.
3.34 Medical Card holders can avail of childcare at reduced rates under the Community Childcare
Subvention Scheme.
33
Medical Card statistics
3.35 Table 2 presents the numbers of full Medical Cards issued by year since 2004 and the numbers
of GP Visit Cards issued since 2005. At the end of July 2014, over 1.8 million Medical Cards
were issued, with a further 142,000 GP Visit Cards issued. Figure 4 illustrates the general trend
regarding the issuing of Medical Cards and GP Visit Cards since 2004.29
Table 2 Numbers of Medical Cards and GP Visit Cards issued 2004-July 2014
Year Medical Card
% population
covered GP Visit Card
% population
covered Total
2004 1,148,914 29.3% N/A N/A 1,148,914
2005 1,155,727 29.5% 5,079 0.13% 1,160,806
2006 1,221,695 28.8% 51,760 1.22% 1,273,455
2007 1,276,128 30.1% 75,589 1.78% 1,351,717
2008 1,352,120 31.9% 85,546 2.02% 1,437,666
2009 1,478,560 34.9% 98,325 2.32% 1,576,885
2010 1,615,809 38.1% 117,423 2.77% 1,733,232
2011 1,694,063 36.9% 125,657 2.74% 1,819,720
2012 1,853,877 40.4% 131,102 2.86% 1,984,979
2013 1,849,380 40.3% 125,426 2.73% 1,974,806
July ‘14 1,804,376 39.3% 142,668 3.11% 1,947,044
Figure 4 Trend in the issuing of Medical Cards and GP Visit Cards
29
Personal communication (A. Smith) 26 August 2014. Office of the National Director of Primary Care, Health
Service Executive
34
3.36 Figure 5 and Figure 6 illustrates the distribution of medical cards by age group comparing 2006
versus 2013.
Figure 5
Figure 6
3.37 The data tables and figures reveal that:
3.37.1 There are over 1.9 million Medical Cards and GP Visit Cards in circulation in Ireland as
of July 2014. This equates to 42.4% of the population.
3.37.2 Population coverage with Medical Cards (full eligibility) has increased steadily from
29.3% in 2004 to just under 40% as of July 2014.
35
3.37.3 The number of Medical Cards (full eligibility) in circulation in Ireland has increased by
over 57% in the period 2004 to August 2014.
3.37.4 In the 65-69 years age category, 52.4% of people have Medical Cards or GP Visit
Cards; 81.8% of those in the 70-74 age category have a Medical Card or GP Visit Card
and 99.2% of those aged over 75 years have a Medical Card or GP Visit Card.
3.38 Statistics on the number of discretionary Medical Cards are only available since 2009. Table 3
summarises the numbers of discretionary Medical Cards in circulation for the period 2009 to
July 2014, while displays the general trend over the same time period.
Table 3 Number and percentage of discretionary Medical Cards
Year
Medical
Card Discretionary % GP Visit Discretionary % Total
2009 1,478,560 79,625 5.4% 98,325 17,221 17.5% 1,576,885
2010 1,615,809 80,524 5.0% 117,423 17,501 14.9% 1,733,232
2011 1,694,063 74,281 4.4% 125,657 16,251 12.9% 1,819,720
2012 1,853,877 63,126 3.4% 131,102 15,833 12.1% 1,984,979
2013 1,849,380 50,294 2.7% 125,426 25,793 12.1% 1,974,806
Jul-14 1,804,376 65,993 3.7% 142,668 28,423 12.1% 1,947,044
Figure 7 Trend in the issuing of discretionary Medical Cards
36
3.39 There are a number of points worth noting:
3.39.1 The number of discretionary Medical Cards has steadily declined since 2010, but
against a background of an increase in the numbers of ‘regular’ Medical Cards.
3.39.2 The notable increase in the numbers of discretionary Medical Cards in the period
end of 2013 to July 2014 is accounted for by the Government’s recent decision to
reinstate cards that had been removed in the period 1 July 2011 to 31 May 2014.
3.39.3 The number of discretionary GP Visit Cards showed a small decline in the period
2009-2012, but since then has seen a noticeable increase.
Medical Card costs
Comptroller and Auditor General – eligibility for Medical Cards
3.40 The Comptroller and Auditor General’s Report on the accounts of the public services 2012
(published September 2013) included an analysis of the administration and costs of Medical
Cards.
3.41 The main components of Medical Card costs are payments to GPs and payments to
pharmacists. Payments to GPs are categorised as fees and/or allowances. Fees are payable in
relation to individual Medical Card patients registered on a per capita basis. GPs are also
entitled to claim out-of-hours payments (where patients are seen outside normal practice
hours) or where special services (excisions, suturing, vaccinations, catheterisation, family
planning etc.) are delivered.
3.42 Drugs and medicines approved under the General Medical Service (GMS) Scheme are provided
through retail pharmacies, and appliances are provided through Local Health Offices. The
pharmacist claims the cost of the medicine provided together with a dispensing fee. The costs
of the medicine provided comprise about three quarters of the total amount paid to
pharmacists.
3.43 In 2002, the HSE paid a total of €823 million to GPs and pharmacists in respect of services
provided to Medical Card users. By 2012, this had increased to just over €1.7 billion. Since
2005, total payments to GPs have ranged from €400 million to €450 million. In contrast,
payments to pharmacists increased from €551 million in 2002 to €1.3 billion in 2012.
37
3.44 The average cost peaked in 2008, when the HSE paid service providers an average of €1,285 in
respect of individuals in possession of a Medical Card. This had fallen to just over €1,000 per
person in 2012.
3.45 The Comptroller and Auditor General made a number of comments and recommendations to
the HSE in relation to the operation of the Medical Card system.
3.45.1 To conduct more internal reviews of Medical Card approvals, in order to ensure that
prescribed controls are being applied. As part of this [C&AG] examination, the
application of controls for the approval of Medical Cards was examined in relation to
a sample of 50 Medical Cards approved during 2012. The review identified
shortcomings in relation to 8% of the sample examined. Some of the shortcomings
resulted in the approval of Medical Card applications in circumstances where the
evidence would suggest that the applicant had not satisfied the eligibility criteria. In
other cases, where outgoings had been assessed, the applicant supplied no
documentation or inadequate documentation.
3.45.2 The available evidence suggests that there is a significant level of excess payment in
the Medical Card system. In the main, this arises as a result of changes in the card
holder’s circumstances over the validity period of the card. The HSE should conduct
reviews of random samples of Medical Card holders on an annual basis.
3.45.3 In order to calculate a reliable estimate of the level of ineligible card holding and the
relevant costs, it is important that all cases for inclusion in the process should be
selected randomly from the population of Medical Card holders at a specific time;
the sample size should be sufficiently large to yield reasonably reliable estimates;
the reviews should be carried out promptly following sample selection; a full review
of eligibility should be conducted; and an assessment of the cost associated with
ineligibility should be calculated with all results capable of being audited.
38
Other Primary Care Schemes and State supports
Drugs Payment Scheme
3.46 Under the Drugs Payment Scheme no individual or family in Ireland will pay more than €144
each calendar month for approved prescribed drugs, medicines and certain appliances for use
by that person or his or her family in that month.
3.47 The definition of a family for this scheme is an adult, their spouse, and any children aged
under 18 years. Dependants over 18 years and under 23 years who are in full-time education
may also be included.
3.48 The Scheme is aimed at those who do not have a Medical Card and normally have to pay the
full cost of their medication. It also applies to those who have a GP Visit Card. Anyone
ordinarily resident in Ireland can apply to join the Scheme, regardless of family, financial
circumstances or nationality.
Long Term Illness Scheme
3.49 People with certain long-term illnesses or disabilities can register under the Long Term Illness
Scheme. This scheme allows a patient to get drugs, medicines, medical and surgical appliances
directly related to the treatment of their illness free of charge. It does not depend on an
individual’s income or other circumstances, and is separate from the Medical Card and the GP
Visit Card. A patient qualifies if they are ordinarily resident in Ireland, hold a Personal Public
Service Number (PPSN) and have one of the following illnesses and disabilities:
• Acute leukaemia
• Mental handicap
• Cerebral palsy
• Mental illness (in a person under 16)
• Cystic fibrosis
• Multiple sclerosis
• Diabetes insipidus
• Muscular dystrophies
• Diabetes mellitus
• Parkinsonism
• Epilepsy
• Phenylketonuria
• Haemophilia
• Spina bifida
• Hydrocephalus
• Conditions arising from the use of
Thalidomide.
39
Dental/ophthalmic and aural services
3.50 The Dental Treatment Services Scheme (DTSS) provides access to dental treatment for adult
Medical Card holders (over 16 years of age). A free oral examination every calendar year and
free emergency dental treatment for relief of pain and sepsis are available to all eligible
patients. This includes two fillings per annum and all extractions.
3.51 Most other treatments require prior approval, and patients with special needs, as well as high-
risk patients and those who have greater clinical needs, receive priority. The DTSS provides
treatment for periodontal/gum disease in cases where care is especially warranted. This
includes clients who are pregnant, have diabetes or immune-compromising conditions, or
require relevant surgical procedures such as cardiac surgery and joint replacements. Approval
for periodontal treatment may be given by the local Principal Dental Surgeon for these and
other high-risk or special needs groups.
High Tech Drug Scheme
3.52 Arrangements are in place for the supply and dispensing of high-tech medicines through
community pharmacies. High-tech medicines are, typically, expensive medicines that have
been produced by biotechnological means, or contain new drugs with significant new
therapeutic uses, or require prescribing by a consultant in a hospital setting.
3.53 High-tech medicines are generally only prescribed or initiated in hospital, and typical examples
would include drugs to prevent transplant organ rejection, as well as some cancer treatments
and assisted reproductive technology medicines. The medicines are purchased by the HSE and
are supplied through community pharmacies, and pharmacists are paid a patient care fee. The
cost of the medicines and patient care fees are paid by the PCRS.
3.54 If an individual has a full Medical Card, or if the medicine is being used to treat one of the
illnesses specified under the Long Term Illness Scheme, then there is no charge for their high-
tech medicine. Patients with eligibility under the Health Amendment Act are also exempt
from a charge. All other patients are required to pay the monthly Drugs Payment Scheme
(DPS) contribution (currently €144).
40
Community Ophthalmic Services Scheme
3.55 Under the Health Service Executive Community Ophthalmic Services Scheme, adult Medical
Card holders and their dependants are entitled, free of charge, to eye examinations and
necessary spectacles/appliances. Claims by optometrists/ophthalmologists are paid by the
PCRS. Claims for spectacles provided under the Children’s Scheme are also paid by the PCRS.
Tax relief and medical expenses
3.56 Any individual who incurs medical expenses that are not covered by the State or by private
health insurance may claim tax relief on some of those expenses. These expenses include the
costs involved in nursing home care. However, it is not possible to claim tax relief for any
expenditure which has been, or will be, reimbursed by another body, such as the VHI, Laya
Healthcare, Hibernian Aviva Health, the Health Service Executive or other body or person; has
been, or will be, the subject of a compensation payment; or relates to routine dental and
ophthalmic care.30
• Costs of doctors’ fees and consultants’ fees
• Items or treatments prescribed by a doctor or consultant
• Maintenance or treatment in a hospital or an approved nursing home
• Costs of speech and language therapy carried out by a speech and language therapist for a
qualifying child
• Transport by ambulance
• Costs of educational psychological assessments carried out by an educational psychologist
for a qualifying child
• Certain items of expenditure in respect of a child suffering from a life-threatening illness
• Kidney patients' expenses
• Specialised dental treatment
• Routine maternity care
• In-vitro fertilisation.
The following, where prescribed by a doctor, also qualify for medical expenses relief:
• Drugs and medicines
• Diagnostic procedures
• Medical, surgical, dental or nursing appliances
• Hearing aids
• Orthopaedic bed or chair
30
http://www.revenue.ie/en/tax/it/leaflets/it6.html
41
• Wheelchair or wheelchair lift (no relief is due for alteration to the building to facilitate a lift)
• Glucometer machine for a diabetic
• Engaging a qualified nurse in the case of a serious illness
• Physiotherapy, chiropody/podiatry services or similar treatment
• Cost of a computer where there is medical evidence that it is necessary to help a person
with a severe disability to communicate
• Cost of gluten-free food for coeliacs. As this condition is generally ongoing, a letter (instead
of prescription) from a doctor stating that the individual is a coeliac sufferer is acceptable.
3.57 Tax relief is also available for premiums paid for health insurance. Tax relief on private health
insurance premiums is limited to €1,000 for each adult and €500 for each child.
42
4. THE VOICE OF THE PUBLIC, THE PATIENT AND REPRESENTATIVE PANELS
Introduction
4.1 In order to assess the public’s opinion as to whether or not medical needs should be taken into
account in the provision of Medical Cards, a public consultation process has been carried out
by the HSE in order to inform the development of a new policy framework for Medical Card
eligibility. There have been two independent component parts of the public consultation
processes.
On-line public consultation exercise
4.2 In June 2014 the Primary Care Division of the HSE invited submissions using an on-line form.
The survey was launched on 6 June 2014 and submissions closed on 30 June 2014. A total of
3,248 responses were received and analysed by the Division of Population Health Sciences,
Royal College of Surgeons in Ireland.
4.3 There were 20 written submissions by disease association/patient advocacy groups to the
Expert Panel; these submissions were too large to be qualitatively analysed by the online
process and were separately analysed by Dr Marie Eagleton, HSE Medical Scientist (this report
is titled Patient Association and Patient Advocacy Group Submissions).
The Patient Representative Forum on Medical Card Eligibility
4.4 The Patient Representative Forum on Medical Card Eligibility was hosted by the HSE National
Advocacy Unit and was held in the Ashling Hotel, Dublin on 26 August 2014.
A summary and the results of each of these exercises are presented below.
On-line public consultation
4.5 In May 2014, the Primary Care Division of the HSE established an on-line public consultation
for submissions to inform the development of a new government policy framework for
Medical Card eligibility. Submissions were requested from the public, patient representative
groups and professional bodies, to inform the work of the Expert Panel in examining the range
of medical conditions that should be considered for inclusion in this new policy framework.
The Public Consultation entitled ‘Have your say on the medical needs that should be taken into
account in the provision of Medical Cards’ invited submissions to be made using an online form
or via email, audio or by post. The closing date for submissions was Monday, 30 June 2014. A
total of 3,248 responses were received via the on-line form.
43
Methods
4.6 The survey asked respondents to provide contact information, such as name, group they were
representing (if applicable), address, telephone number and email address. The remainder of
the survey comprised 11 open-ended (free text) questions and 8 pre-coded questions.
Respondents were asked to indicate if they were a person living with a condition, or if they
were an individual or group connected in some other way. Detailed information on medical
needs that arise based on these conditions was elicited by asking participants to provide the
following information in free text comment boxes: medical condition(s); reasons why this
condition should be considered on the basis of medical need; GP visits e.g. number, frequency
of visits etc.; medicines e.g. range of medications required; therapies e.g. occupational
therapy, physiotherapy and other therapy support needs and frequency; aids and appliances
e.g. home support equipment and other medical devices; in-patient treatments, e.g., hospital-
based care needs; respite care requirements; other. Participants were then asked to provide
ratings (from ‘Not at all’ to ‘Very much’) of how much their condition typically effects their
normal activity; physical function; mental health; social function; energy; pain; work. A final
free text comment box prompted participants to include any further relevant information they
wished to add. All records were anonymised before analysis was undertaken.
Analysis
4.7 This report presents analysis of the 3,248 on-line submissions. Descriptive statistics of
responses are presented, where quantitative summation was possible. Free text responses
were analysed qualitatively. Qualitative analysis involved assigning categories based on the
criteria of repetition, recurrence and forcefulness of various topics or themes in the responses
to the open-ended questions. These categories were used to code the open-ended question in
the analysis. The open-ended responses were further analysed to provide exemplars of a
particular topic or theme and were used to highlight in this report the key issues raised.
Summary of key findings
4.8 The quantitative analysis indicated high health service utilisation among this group, with 40%
visiting the GP between five and twelve times a year. A small minority (less than 2%) do not
take any medication, while a third of respondents take five or more medications. Almost half
of respondents indicated needs for hospital services; 50.5% of respondents and 30% of
respondents indicated need for in-patient and out-patient services, respectively. Other
therapy (including alternative and complementary therapies) as well as technical aids and
appliances are also an area of great need for people. Just over half mentioned the need for
physiotherapy and almost 12% mentioned needing some form of complementary therapy;
44
42.5% mentioned use or need of multiple aids and appliances. These findings combine to
highlight the broad range of services required to support individuals and their families not only
to live a life with chronic illness, but to live a life that is full, complete and inclusive, providing
equitable opportunity and choice in all aspects of life. Qualitative analysis of the free text
responses provides insight into the challenges faced by people in accessing the appropriate
services at the appropriate time. Poor health and unmet health needs were reported as having
a domino effect on all other aspects of an individual’s life, ultimately impacting on society as a
whole.
Financial impact
4.9 Respondents alluded to difficult decisions being made between accessing GP services for their
children or another family member to the detriment of their own health; foregoing necessary
GP and/or hospital visits due to cost. A recurring theme also was restricting medication use,
again due to cost. Going abroad to source cheaper medications or specialist care not available
in Ireland was a strategy followed by some. Sourcing medication or specialist care in this way
added to the financial burden for those with the health condition and their families, and also
created logistical, travel and emotional stress for the individual and their family.
Emotional impact
4.10 The sense of worry, anxiety and stress associated with access (or not being able to access)
appropriate health care, and financial concerns associated with cost of care and medications
were prominent throughout the submissions.
Family impact
4.11 The impact on family was also clear. Respondents noted how other children within the family
may not receive equal attention, or how families may not be able to take holidays due to
providing care and the cost of care of one sibling. Stress and strain in caring for family
members was reported in addition to the huge responsibility placed on families to administer
medical/therapeutic care at home.
Impact on work/schooling
4.12 The individual is often faced with the decision to work (and lose the much-needed Medical
Card) or to keep the card but not work. The submissions indicate the negative impact that not
working or missing work due to illness can have on the individual’s sense of self, quality of life,
and ability to contribute in a meaningful way both economically and socially. Education is also
45
impacted through reduced attendance at school, due to illness or hospital/clinic
appointments. Participation in school life is affected by access to appropriate supportive aids,
and also the extent to which recreational/sporting activities can be inclusive of all children. In
many cases, children with chronic illness are excluded from such activities and it is the family
who supplement these activities outside school hours.
Conclusion
4.13 Overall, the findings of the online public consultation survey highlight that having a chronic
illness is not about diagnosis alone. Respondents in the consultation indicated that the
overriding challenge for individuals and families alike is accessing the required health services
while also balancing all other aspects of life (work, family, mental health). In particular, the
challenge most prominently reported is the ongoing difficulty of trying to balance the
individual and/or family budget to enable access to care for all as needed. As one participant
surmised:
“It’s hard enough trying to cope with a chronic illness without the expense and stress making
my future look so bleak.”
Patient association and patient advocacy group submissions31
4.14 There were twenty submissions by disease association/patient advocacy groups to the Expert
Panel on Medical Card Eligibility, and there were six individual submissions. The twenty group
submissions are listed below. All diseases and conditions were chronic, lifelong or had a
relapsing-remitting course. The submissions varied in the level of detail supplied, but a number
of common themes emerged.
4.14.1 Respondents strongly urged that allocation of Medical Cards should be based on
medical need rather than having a medical condition. The prevalence of a condition
should not be a basis for entitlement to a Medical Card, and respondents do not want
to see a situation where there would be competition between conditions for Medical
Cards. An objective assessment of medical need would avoid this; Medical Cards
should be about medical need, and personal financial circumstances should not be
taken into account when assessing for a discretionary Medical Card.
31
Twenty written detailed submissions were received by disease association/patient advocacy groups and a
further six were submitted by individuals.
46
4.14.2 It was acknowledged that medical need could be transient in nature and that a
mechanism for rapid assessment of medical need would be developed. This would
facilitate issue of Medical Cards when they were needed, and withdrawal of these
cards if and when the disease was in remission.
4.14.3 It was noted that accessing community-based services without a Medical Card is
difficult, and that paying for necessary aids and appliances is financially burdensome.
The following is a quote from the Irish Cancer Society Submission:
“…patients who do not have a Medical Card face significant costs to care for
themselves at home. What is particularly stark is that without a Medical Card they do
not have guaranteed access to a public health nurse or allied community-based
professionals.”
4.14.4 Many of the respondents indicated that the current system for allocation of medical
cards did not discern the true cost of chronic illness. Some submissions provided
information on the cost of these illnesses to patients and their families, which
significantly reduces their disposable income. The prospect of withdrawal of
discretionary Medical Cards by those who already have them provokes a lot of anxiety
in families.
4.14.5 Many patients with chronic conditions who do not have Medical Cards pay up to the
maximum for prescription drugs every month and visit GPs more frequently than
normal, which causes undue financial hardship. Furthermore, in addition to paying the
maximum for medication, some patients pay for essential supplements and drugs not
covered by the Drugs Payment Scheme (DPS), and may often have to pay for other
therapies: chronic disease incurs a lot of expense.
4.14.6 There are anecdotal reports that people with chronic conditions who do not have
Medical Cards do not fully comply with medication, or attend the GP or hospital
appointments with necessary regularity, for financial reasons.
4.14.7 The respondents indicated that many people with chronic illnesses who already have
Medical Cards are uninclined to take up employment because they may lose their
Medical Card on financial grounds. This further increases their dependency on the
State and has a detrimental effect on their wellbeing.
47
4.14.8 It was noted by some respondents that having a Medical Card opens up other non-
medical benefits such as free school bus service, and decoupling of these services was
urged.
4.14.9 Many of the submissions commented on the administration of Medical Cards and how
difficult it is for the individual to navigate the system, which is seen as overly
bureaucratic, inaccessible and insensitive in its approach to ill people.
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